Apply Helping Pets in Need of Medical Care | Porter-Rinsky Foundation Porter-Rinsky Foundation

Pet Owner Full Name(Required)

Street Address(Required)

Street Address Line 2(Required)

City(Required)

State(Required)

Zip Code(Required)

Please enter a number from 00001 to 99950.

Phone(Required)

Email(Required)

Pet Name(Required)

Type of Pet

Dog

Cat

Pets Age(Required)

Please enter a number from 0 to 30.

How long have you owned your pet?(Required)

How many total household pets?(Required)

Is your pet spayed or neutered?(Required)

Name of emergency/specialty veterinary hospital where your pet is being treated:(Required)

Doctors Name(Required)

Clinic Phone Number(Required)

Clinic Address(Required)

Diagnosis(Required)

Describe the medical problem and treatment solutions in your own words:(Required)

Total Amount of Invoice(Required)

When did you apply for Care Credit or Scratch Pay?

Were you approved?

Yes

Total amount already paid towards the cost of the pet's treatment? (Required)

How much have you secured through donations from family, friends, Gofundme.com, etc?(Required)

Do you have veterinary insurance?

Yes

If you have insurance, what is the amount your policy will reimburse? (Required)

Have you asked the hospital for a discount?

Yes

How much of a discount is the hospital willing to provide?(Required)

Please check each boxes that applies to your current financial information:(Required)

I am currently employed

I am currently unemployed

I receive social security or disability benefits

I receive government assistance

We do not qualify for a credit card

We do not have pet insurance

My family's household income is below the poverty level (please visit https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines for more detials)

Please describe the hardship you claim:(Required)

Last year's household income:(Required)

Projected household income this year:(Required)

Number of total people in household::(Required)

Total monthly household bills:(Required)